Recurring ACH Payment Authorization Form



Recurring ACH Payment AuthorizationThis form will authorize regularly scheduled charges to your checking/savings account for the PPCN monthly participation fee. You will be charged the amount indicated below each billing period. If you previously provided a credit card, this switch will be made at the first of the next month. A receipt for each payment will be emailed to you and the charge will appear on your bank statement as an “ACH Debit”. You agree that no further prior-notification for this charge will be provided unless the date or amount changes, in which case you will receive notice from us at least 10 days prior to the payment being collected.I ______________________________________________ authorize the Pennsylvania Pharmacists Association/ PA (print your name)Pharmacists Care Network to charge my bank account indicated below the following amount monthly for the PPCN enrollment fee of $119.00**If you were an early adopter, we will adjust this amount to $99. If your monthly fee is partially subsidized by Value Drug Company, we will also adjust this fee.Pharmacy Name(s) and NPIs:Billing InformationStreet Address ______________________________________________________ Phone #______________________________City, State, Zip _______________________________________________________ Email _________________________________4678680107950*Your bank?routing number?is a nine-digit code that's based on the U.S. Bank location where your account was opened. It's the first set of?numbers?printed on the bottom of your checks, on the left side. You can also find it?by searching online or contacting your financial institution. 00*Your bank?routing number?is a nine-digit code that's based on the U.S. Bank location where your account was opened. It's the first set of?numbers?printed on the bottom of your checks, on the left side. You can also find it?by searching online or contacting your financial institution. Bank Details Checking ? Savings ?Bank Name: _________________________________________________________________ Account Number: __________________________________________________________ Routing Number: ___________________________________________________________I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the Pennsylvania Pharmacists Association in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day.?For ACH debits to my checking/savings account, I understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates.?In the case of an ACH Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Pennsylvania Pharmacists Association may at its discretion attempt to process the charge again within 30 days, and agree to an additional $40 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law.?I certify that I am an authorized user of this bank account and will not dispute these scheduled transactions with my bank; so long as the transactions correspond to the terms indicated in this authorization form. SIGNATURE _____________________________________________ DATE _____________________ (Account Holder’s Signature)Please Fax to PPA at 717-236-1618. DO NOT EMAIL THIS FORM! ................
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